At Total Family Eye Care we promise to care for and treat every patient’s eye care and health with utmost attention and respect. We will provide the highest quality of care available and stand behind our eyewear. Your eye health and quality of life will always be our focus.

Insurance Information

Vision Plan

ID#

Subscriber Name

Subscriber SSN

Subscriber Birth Date

(mm/dd/yyyy)

Primary Medical Insurance

Insurance number on card

Subscriber Name

Subscriber SSN

Subscriber Birth Date

(mm/dd/yyyy)

Do you participate in a flex spending account?

YesNo

How will you settle your account today?

Cash
Check
Credit Card

Lifestyle Questions

Do you work at a computer?

YesNo

Do you think you might benefit from thinner, lighter lenses?

YesNo

Do you have interest in a “test drive” of the latest contact lens
designs?

YesNo

Do you have prescription sunwear?

YesNo

Do you prefer not to wear your glasses at times?

YesNo

Do you want information on Laser Vision Correction surgery?

YesNo

Do you have more than 1 pair of current Rx eyewear?

YesNo

Do you have children?

YesNo

Have you ever experienced, been diagnosed or treated for any of the following?